Blue PPO Silver SM 003 Coverage Period: 1/1/ /31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs

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1 Important Questions What is the overall? This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling Are there other s for specific services? Is there an out-of-pocket limit on my expenses? What is not included in the out-of-pocket limit? Does this plan use a network of providers? Do I need a referral to see a specialist? Answers Preferred Provider $6,000/Individual. $12,700/ Family. Non-Preferred Provider $12,000/ Individual. $25,400/Family. Doesn't apply to in-network preventive care, services that charge a copay, or prescription drugs. Copays, per occurrence s, and prescription drug costs don't count toward the overall. Yes. There are additional per occurrence s: ER $500; Inpatient $250/$350; and Outpatient $200/$300. There are no other specific s. Yes. Preferred Provider $6,000/Individual. $12,700/ Family. Non-Preferred Provider $12,000/Individual. $25,400/ Family. Premiums, balance-billed charges, and health care this plan doesn't cover. Yes. Please call or see No. You don't need a referral to see a specialist. Why this Matters: You must pay all the costs up to the amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the starts over (usually, but not always, January 1st). See the chart starting on page 3 for how much you pay for covered services after you meet the. You must pay all the costs for these services up to the specific amount before this plan begins to pay for these services. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don't count toward the out-of-pocket limit. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 3 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Blue Cross and Blue Shield of New Mexico, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 1 of 9

2 Important Questions Are there services this plan doesn't cover? Answers Yes. Why this Matters: Some of the services this plan doesn't cover are listed on page 6. See your policy or plan document for additional information about excluded services. 2 of 9

3 Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the health plan's allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven't met your. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) The plan may encourage you to use preferred providers by charging you lower s, copayments, and coinsurance amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test Services You May Need Primary care visit to treat an injury or illness Specialist visit Other practitioner office visit Preventive care/screening/immunization Diagnostic test (x-ray, blood work) Imaging (CT / PET scans, MRIs) a Preferred Provider $30 copay/visit $50 copay/visit No Charge a Non-Preferred Provider Limitations & Exceptions Acupuncture treatment and chiropractic care each limited to 25 visits/year, unless for rehabilitative or habilitative purposes. 3 of 9

4 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at member/rx_drugs.html If you have outpatient surgery If you need immediate medical attention If you have a hospital stay Services You May Need Preferred generic drugs Non-preferred generic drugs Preferred brand drugs Non-preferred brand drugs Specialty drugs Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Emergency room services Emergency medical transportation Urgent care Facility fee (e.g., hospital room) Physician/surgeon fee a Preferred Provider No Charge $10/Retail-$20/Mail $50/Retail-$100/Mail $100/Retail-$200/ Mail $150/prescription $200 per occurrence $500 per occurrence $75 copay/visit $250 per occurrence a Non-Preferred Provider 50% coinsurance $10/Retail plus additional 50% coinsurance $50/Retail plus additional 50% coinsurance $100/Retail plus additional 50% coinsurance $150/prescription plus additional 50% coinsurance $300 per occurrence $500 per occurrence $75 copay/visit $350 per occurrence Limitations & Exceptions Retail-limited to a 30-day supply. Mail-order limited to a 90-day supply, in-network only. Specialty drugs are not available through mail-order. Out-of-network specialty drug coverage is limited to certain medications that are clarified in the prescription drug rider. Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available. Per occurrence is in addition to the overall. Elective abortion is not covered. Per occurrence is in addition to the overall and is waived if admitted. Preauthorization required for non-emergency air ambulance. Per occurrence is in addition to the overall. Preauthorization required. 4 of 9

5 Common Medical Event If you have mental health, behavioral health, or substance abuse needs If you are pregnant If you need help recovering or have other special health needs Services You May Need Mental/Behavioral health outpatient services Mental/Behavioral health inpatient services Substance use disorder outpatient services Substance use disorder inpatient services Prenatal and postnatal care Delivery and all inpatient services Home health care Rehabilitation services Habilitation services Skilled nursing care Durable medical equipment Hospice service a Preferred Provider $30 copay/visit $250 per occurrence $30 copay/visit $250 per occurrence $30/$50 copay/visit $250 per occurrence a Non-Preferred Provider $350 per occurrence $350 per occurrence $350 per occurrence Limitations & Exceptions Includes office, home, outpatient, and IOP services; inpatient and partial hospitalization (IOP, partial hospitalization, & inpatient require preauthorization). Per occurrence is in addition to the overall. Copay charged for initial visit only. Per occurrence is in addition to the overall. Max. 100 visits/year. Includes physical, occupational, and speech therapies in an office or outpatient setting. Max. 60 days/year. 5 of 9

6 Common Medical Event If your child needs dental or eye care Services You May Need Eye exam Glasses Dental check-up Excluded Services & Other Covered Services: a Preferred Provider No Charge Covered Not Covered a Non-Preferred Provider Covered Covered Not Covered Limitations & Exceptions One visit per year. Reimbursed up to $40 out-of-network. One pair of glasses per year. Up to $100 in-network. Reimbursed up to $50 out-of-network. Coverage is under your stand-alone dental plan. See dental plan information for details. Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.) Cosmetic surgery Private-duty nursing Routine foot care (Unless you are diabetic) Dental Care (Routine dental for adults) Routine eye care (Adult) Termination of pregnancy (Except in limited Long-term care circumstances) Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.) Acupuncture (Max. 25 visits/year) Hearing aids (Up to age 21) Non-emergency care when traveling outside the Bariatric surgery (Based on medical necessity) Infertility treatment (Diagnosis and treatment of U.S. Chiropractic care (Max. 25 visits/year) medical condition causing infertility) Weight loss programs (Health education and counseling services) Your Rights to Continue Coverage: Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are exceptions, however, such as if: You commit fraud The insurer stops offering services in the State You move outside the coverage area 6 of 9

7 For more information on your rights to continue coverage, contact the insurer at You may also contact the Office of Superintendent of Insurance toll-free at Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you may also contact the Office of Superintendent of Insurance toll-free at or Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan or policy does provide minimum essential coverage. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa Chinese ( 中文 ): 如果需要中文的帮助, 请拨打这个号码 Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' To see examples of how this plan might cover costs for a sample medical situation, see the next page. 7 of 9

8 Coverage Examples: About These Coverage Examples: Blue PPO Silver SM 003 Coverage Period: 1/1/ /31/2015 Having a baby (normal delivery) Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $7,540 Amount owed to providers: $5,400 These examples show how this plan might cover Plan pays $1,390 Plan pays $2,900 medical care in given situations. Use these Patient pays $6,150 Patient pays $2,500 examples to see, in general, how much financial protection a sample patient might get if they are Sample care costs: Sample care costs: covered under different plans. Hospital charges (mother) $2,700 Prescriptions $2,900 Routine obstetric care $2,100 Medical Equipment and Supplies $1,300 Hospital charges (baby) $900 Office Visits and Procedures $700 This is not a Anesthesia $900 Education $300 cost Laboratory tests $500 Laboratory tests $100 estimator. Prescriptions $200 Vaccines, other preventive $100 Don t use these examples to Radiology $200 Total $5,400 estimate your actual costs under Vaccines, other preventive $40 the plan. The actual care you Total $7,540 Patient pays: receive will be different from these Deductibles $2,420 examples, and the cost of that care Patient pays: Copays $0 also will be different. Deductibles $6,000 Coinsurance $0 Copays $0 Limits or exclusions $80 See the next page for important Coinsurance $0 Total $2,500 information about these examples. Limits or exclusions $150 Total $6,150 8 of 9

9 Coverage Examples: Blue PPO Silver SM 003 Coverage Period: 1/1/ /31/2015 Questions and answers about Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from in-network providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how s, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-of-pocket costs, such as copayments, s, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. 9 of 9